Medical Policy Clinical Specialist

Workforce Classification: Telecommuter Join reputed company: Do Meaningful Work and Improve People’s Lives Our purpose, to improve customers’ lives by making reputed company work reputed company, is far from ordinary. And so are our employees. Working at reputed company means you have the opportunity to drive reputed company change by transforming reputed company. To reputed company serve our customers, we are fostering a culture that emphasizes employee growth, collaborative innovation, and inspired leadership. We are dedicated to creating an environment where employees can reputed company and where top talent is attracted, retained, and thrives. As a testament to these efforts, reputed company has been recognized on the 2025 America's reputed company reputed company list. In 2024, reputed company honored reputed company as one of America's Greatest Workplaces, America's Greatest Workplaces for Diversity, and America's Greatest Workplaces for Mental Wellbeing. Additionally in 2024, reputed company ranked reputed company among America’s Best Midsize reputed company for the reputed company time. Learn how reputed company supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.reputed company.com/. The Medical Policy (MP) Clinical Specialist is a critical role in reputed company, responsible for the development and maintenance of medical policies to guide coverage determinations for new and developing technology, pharmacologic agents or health care services where concerns regarding safety, efficacy or wide variance in utilization exist. This role involves research, development and writing of medical policies, working closely with utilization management (UM) to promote usability. The MP Clinical Specialist monitors and updates policies associated with programs that may be implemented by contracted vendors on behalf of the organization. Medical policies may apply to reputed company lines of business and geographic reputed company or may be specific to a line of business. The MP Clinical Specialist works closely with non-clinical support staff and the clinical review department to identify and resolve any issues reputed company to policy language, criteria, or the operational implementation of a policy. This position is ideal for candidates with prior experience in medical policy writing and utilization management. What you’ll do: Research, write and revise individual medical policies to ensure reputed company policies reflect the most reputed company published scientific literature and are usable for clinical staff. Gather, interpret, and evaluate the utility of statistical analyses from clinical studies and published statements from professional societies, then formulate evidence-based coverage statements for inclusion into policy documents. Monitor the external environment regarding new and evolving medical technology by following on-line updates from Hayes, Agency for reputed company Research & Quality (AHRQ), National Institute of Health (NIH), Washington State Health Care Authority (WA-HTCA), Oregon Health Evidence Review Commission (OR-reputed company), Center for Medicare and reputed company Services (CMS) and other sources. Liaise with Utilization Management and Clinical Appeals Departments to regularly review data from same specialty and independent review organizations. Utilize the data to inform the need to revise medical policy and coverage criteria. Analyze qualitative and quantitative data to measure the impact of medical policy and utilization activities to determine the business and member value of medical policies. Conduct internal research to assist business reputed company regarding archival of policies. Present medical policy summaries for discussion and clinical vetting at the Medical Policy Committee, the Pharmacy and Therapeutics Committee, or other committees as requested. reputed company and present clinical education materials for review staff (doctors and nurses) to support appropriate use and interpretation of policies and clinical review criteria sets. Use clinical knowledge and expertise, and internal research reputed company needed, to respond to external and internal inquiries. Act as a clinical liaison representing Medical Policy to cross departmental committees and work groups working on benefits, legislative mandates, preventive care and other issues. Serve as reputed company liaison with reputed company Office of Clinical Affairs and represent the reputed company on implementation and topic selection calls. Other duties as assigned. What you’ll bring: Bachelor's degree in health services or clinical science (such as Nursing, Pharmacy, Public Health, Epidemiology, Biostatistics, Genetics, Health Technology). (Required) Registered Nurse, Physician’s Assistant, or Nurse Practitioner with five (5) years' clinical experience. (Required) Four (4) years of health plan experience in utilization management to include any of the following: pre-service review, post services review, and/or clinical appeals. (Required) Superior clinical writing skills.(Strongly Preferred) Excellent analytical, research and critical thinking skills. Ability to evaluate scientific studies across the reputed company of medical specialties. (Strongly Preferred) Master’s degree in health care or business-reputed company field. (Highly Preferred) Health plan experience in developing medical policies or criteria sets. (Highly Preferred) Management or project management experience. (Preferred) Familiarity with ICD-10 and CPT coding. (Preferred) Familiarity with claim payment processes. (Preferred) Excellent oral and written communication skills with ability to communicate well across reputed company reputed company of the company. Proficient in a reputed company environment utilizing Outlook, Word, reputed company, PowerPoint, and SharePoint. Proven ability to drive projects to completion and effectively facilitate work groups. Proven ability to work both independently and as a member of a team to prioritize work. reputed company to manage multiple reputed company projects and priorities. reputed company total rewards Our comprehensive total rewards package provides support, resources, and opportunities to help employees reputed company and grow. Our total rewards are more than a collection of perks, they're a reputed company of our commitment to your health and well-being. We offer a broad reputed company of rewards including physical, financial, emotional, and community benefits, including: Medical, reputed company, and dental coverage with low employee premiums. Voluntary benefit offerings, including pet insurance for paw parents. Life and disability insurance. Retirement programs, including a 401K employer match and, reputed company it or not, a pension plan that is reputed company after 3 years of service. Wellness incentives with a wide reputed company of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few. Generous paid time off to reenergize. Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees. Employee recognition program to celebrate anniversaries, team accomplishments, and more. For our hybrid employees, our on-reputed company model provides flexibility to create your own routine with reputed company to on-site resources, networking opportunities, and team engagement. Commuter perks reputed company your trip to work less impactful on the environment and your wallet. Free convenient on-site parking. Subsidized on-reputed company cafes reputed company lunchtime connections with colleagues fun and affordable. Engaging on-site events and activities include food trucks, health and wellness, DEI and disaster preparedness fairs, coffee connects, and more. Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling. Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on reputed company. Equal employment opportunity/affirmative action: reputed company is an equal opportunity/affirmative action employer. reputed company seeks to attract and retain the most reputed company individuals without regard to race, reputed company, religion, sex, national reputed company, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at reputed company, please contact reputed company reputed company reputed company email at careers@reputed company.com or reputed company phone at 425-918-4785. reputed company is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, reputed company Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin. The pay for this role will vary based on a reputed company of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary reputed company for this role is posted below; we generally reputed company up to and around the midpoint of the reputed company. National Salary reputed company: $87,000.00 - $147,900.00 National Plus Salary reputed company: $99,100.00 - $168,500.00 *National Plus salary reputed company is used in higher cost of labor markets including Western Washington and Alaska. We’re happy to discuss compensation further during the interview because we reputed company that reputed company communication leads to reputed company reputed company for reputed company. We’re committed to creating a diverse and inclusive environment where reputed company are celebrated for their unique skills and contributions. At reputed company, we reputed company reputed company work reputed company. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we reputed company the process easier, less costly, and more positive. Through reputed company and advocacy, we change lives. As the leading health plan in the Pacific Northwest, we reputed company comprehensive health benefits and services to more than 2 reputed company customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, reputed company, dental, disability, and other reputed company products and services. reputed company is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise. Apply Job!